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Fig. 23.4 Bilateral lower
extremity lymphedema in a
56-year-old man before and
after complex decongestive
therapy. ( a ) Before treat-
ment. Note the signifi cant
limb swelling and chronic
skin changes (lichenifi cation,
warty projections, and
cobblestone appearance)
associated with lymphedema.
( b ) After treatment. Note the
signifi cant improvement in
limb swelling and chronic
skin changes
J. Laredo and B.B. Lee
a
b
lymphedema with a female to male ratio of 10:1. It
is usually unilateral and often limited to the foot
and calf in most patients (Fig. 23.3 ) [ 2 , 8 , 11 ].
23.6 Secondary Lymphedema
Secondary lymphedema is far more common than
primary lymphedema and represents 90 % of cases
of lymphedema. The most common causes of lower
extremity lymphedema are tumor (e.g., lymphoma,
prostate cancer, ovarian cancer), surgery involving
the lymphatics, radiation therapy, obesity, trauma,
and infection. Worldwide, infection with the
parasitic nematode Wuchereria bancrofti (also
known as fi lariasis) is the most common cause of
lymphedema (Fig. 23.3 ) [ 2 , 4 , 8 ].
23.7 Diagnosis
23.7.1 Clinical Evaluation
Evaluation of patients with lymphedema must
include a detailed, careful history and thorough
physical examination [ 3 , 4 , 7 , 11 , 12 ]. The his-
tory should include age at onset, travel to tropical
countries, and history of all causes that could
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Fig. 23.5 Clinical signs of
lymphedema. ( a ) Positive
Stemmer’s sign (a failure by
the examiner to pick up or
pinch a fold of skin at the
base of the second toe).
( b ) Buffalo hump on the
dorsum of the left foot in
a patient with lymphedema
333
a
b
result in secondary lymphedema such as surgery,
malignancy, venous insuffi ciency, trauma, and
cellulitis. A history of temporary edema of the
affected limb or other areas must be noted, and a
detailed family history of limb swelling should
also be recorded.
Signs and symptoms of lymphedema should
be documented. These include nonpitting
edema, skin changes such as “peau d’orange,”
pinkish- red skin discoloration, hyperkeratosis, dermatitis, eczema, ulceration, varicosity,
lymph vesicles, warty projections, drainage of
fl uid (clear or milky), or yellow discoloration
or other abnormalities of the nails (Fig. 23.4 ).
The presence of Stemmer’s sign (inability to
pinch a fold of skin at the base of the second
toe) or puffi ness of the forefoot (buffalo hump)
should be noted (Fig. 23.5 ) [ 3 , 7 , 11 , 12 ]. The
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J. Laredo and B.B. Lee
presence of venous, arteriovenous, or capillary
malformations and any limb length discrepancy
should be recorded. Finally, any complications
such as cellulitis, lymphangitis, malnutrition,
and immunodefi ciency or, rarely, suspicion for
malignancies (lymphangiosarcoma) must be
documented [ 3 , 7 , 11 ].
23.7.2 Noninvasive Radiologic
Studies
Plain fi lm X-rays will identify limb length discrepancies, bone abnormalities, or phleboliths in
patients with combined lymphatic malformations
and venous malformations [ 7 , 11 ].
Venous duplex studies will confi rm any associated venous anomalies (valvular incompetence,
obstruction, ectasia, or aneurysms) and assess for
venous obstruction as an etiology or contributing
factor to lymphedema [ 7 , 11 ].
23.7.3 Minimally Invasive Radiologic
Studies
Radionuclide Lymphoscintigraphy
This study is performed with a subcutaneous
injection of 99mTc-labeled human serum albumin (HAS) or 99mTc-labeled sulfur colloid (SC)
into the fi rst and second web space of the toes
(fi ngers), followed by radionuclide scanning at
various time intervals [ 7 , 11 ]. It is the test of
choice to confi rm or exclude lymphedema as the
cause of chronic limb swelling. Removal of the
colloid from the injection site; appearance time
of activity at the knee, groins, or axilla; absence
or presence of major lymphatic collectors; number and size of vessels and nodes; the presence of
collaterals and refl ux; and symmetric activity
with the opposite side are recorded and used for
interpretation.
An appropriate combination of non- to minimally invasive tests normally should provide all
the information necessary to insure an adequate
diagnosis and lead to the correct multidisciplinary, specifi cally targeted and sequenced
treatment strategy. The tests and the information
they provide are indicated here [ 11 ].
Basic/essential tests:
Radionuclide lymphoscintigraphy
MRI with/without contrast for the differential
diagnosis
CT scan to exclude underlying pathology
Duplex ultrasonography
Optional tests:
Whole body blood pool scintigraphy (WBBPS)
Magnetic resonance (MR) and/or ultrasound
lymphography
Volumetry
Bio-impedance spectrometry
Air plethysmography
Ultrasonographic lymphangiography: investiga-
tional for the reconstructive surgery candidate
patient
MR lymphangiography: investigational for the
reconstructive surgery candidate patient
Microscopic fl uorescent lymphangiography:
investigational for phlebolymphedema
Radionuclide lymphoscintigraphy is the
most essential part of the diagnosis of lymphedema in addition to clinical evaluation. This
study is extremely useful for delineating the
specifi c lymphatic abnormality and has largely
replaced conventional oil contrast lymphography for visualizing the lymphatic network.
Lymphoscintigraphy remains the gold standard
for the lymphatic function evaluation, which is
recommended for proper clinical management
[ 3 , 7 , 11 ].
On some occasions an invasive study is
required for an accurate diagnosis. These tests
and the information they provide are listed below:
Direct puncture percutaneous lymphangiography
Standard (ascending) lymphangiography
Indirect lymphography using water-soluble con-
trast media
Fine needle aspiration biopsy of lymph node
Skin biopsy in cases of suspected sarcoma and
skin cancer or differential diagnosis of warty
lesions
Invasive tests are seldom required for diagnosis but are occasionally needed for confi rming
the diagnosis or planning surgical therapy.
Conventional oil contrast lymphangiography,
especially if coupled with computed tomography
(CT) scanning, is still advantageous in selected
patients with chylous dysplasia and gravitational
23 Lymphedema
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335
refl ux disorders in order to defi ne more clearly
the extension of the pathologic alterations and
sites of lymphatic and chylous leakage [ 11 ]. It is
the only diagnostic study that can clearly demonstrate pathologies of chylous vessels, chylous
cyst, and thoracic duct in cases of chylothorax,
chylous ascites, protein-losing enteropathy, etc.
As a part of the diagnostic procedure, the
systemic causes of edema (e.g., heart failure,
hypoproteinemia, pulmonary hypertension, hypothyroidism, cyclic edema) should be ruled out.
Duplex ultrasonography should be performed
initially in all forms of lymphedema to assess for
concomitant venous disease.
Diagnostic evaluation should also include
appropriate assessment of the patient’s understanding of the disease process and ability to be
compliant with the treatment regimen, since the
outcome of successful management is totally
dependent on the patient’s active participation in
the care of his or her lymphedema.
23.8 Treatment of Lymphedema
23.8.1 General Considerations
The importance of patient education and compliance cannot be overemphasized when treating
patients with both primary and secondary lymphedema. The patient must fi rst understand that
lymphedema is a chronic condition and will
never be completely cured. In addition they must
also understand that there is no “quick fi x” operation, medication, or therapy that will completely
reverse the clinical condition. Treatment of
lymphedema is essentially management of the
medical condition and prevention of progression
of the disease process. Lymphedema can be successfully managed.
The goals of lymphedema therapy are to arrest
progression, reduce swelling, maintain that
reduction, prevent infection, restore mobility and
range of motion, and train patients for selfmanagement [ 4 , 10 , 14 ].
The treatment of lymphedema requires diligence and motivation on the part of the patient.
The patient must be an active, compliant participant for successful management. The mainstay of
lymphedema treatment is through physical therapeutic measures occurring in the setting of a specifi c lymphedema therapy program, performed
by specially trained lymphedema therapists [ 3 ,
10 , 14 , 15 ].
23.8.2 Physical Treatments
Physical treatment to reduce swelling is aimed at
controlling lymph formation and improving
lymph drainage through existing lymphatic vessels and collateral routes by applying normal
physical processes which stimulate lymph fl ow
(Table 23.2 ) [ 3 , 10 , 12 , 14 – 16 ]. Manual therapies
in multiple forms remain the most widely used
interventions for the therapeutic management of
lymphedema, regardless of etiology.
Table 23.2 Physical treatments for lymphedema
Treatment Effect
Exercise Dynamic muscle contractions
encourage movement of lymph
along tissue planes and
noncontractile, initial lymph
vessels (passive drainage) and
increased contractility of collecting
lymph vessels (active drainage)
Compression
garments
Manual lymphatic
drainage
Compression
bandaging
Pneumatic
compression
Elevation Does not stimulate lymph
Opposes capillary fi ltration
Acts as a counterforce to muscle
contractions generating greater
interstitial pressure changes
Form of massage therapy that
stimulates lymph fl ow in more
proximal, normally draining
lymphatics to “siphon” lymph
from congested areas
Used as an intensive treatment in
combination with exercise to
reduce large, misshapen lower
limbs and permit subsequent
maintenance treatment with
compression stockings
Softens and reduces limb volume
but can forcibly displace fl uid into
the trunk and genitalia.
Compression garments must be
worn after treatment
drainage, but lowers venous
pressure and therefore capillary
fi ltration, allowing lymph drainage
to catch up
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J. Laredo and B.B. Lee
Table 23.3 Complex decongestive therapy
Phase I: intensive reduction therapy
Manual lymphatic drainage massage
Multilayered low-stretch wrapping techniques
Specifi c exercise regimen
Skin care education and techniques
Phase II: maintenance therapy
Daily wear of pressure garment
Continued nightly multilayered wrapping
Self-manual lymphatic drainage massage
Exercise
Continued meticulous skin management
Manual lymphatic drainage (MLD) is a highly
specialized form of massage therapy that employs
very light and gentle cutaneous distension to
enhance lymph transport. MLD is believed to
stimulate and increase the intrinsic contractility
of lymph collecting vessels and encourage
increased protein molecule sequestration and
subsequent transport [ 10 , 14 – 16 ]. MLD is often
combined with other manual therapies including
compression bandaging, exercise regimens, skin
care techniques, pressure gradient garments, and
pneumatic compression devices [ 15 – 20 ].
Complex decongestive therapy (CDT) is a combined approach to lymphedema therapy that has
been standardized by multiple international lymphatic treatment organizations and specialized
lymphedema treatment programs [ 10 , 14 – 16 ]. The
treatment regimen is composed of two phases:
intensive reduction therapy followed by maintenance therapy (Table 23.3 ). This treatment regi-
men utilizes MLD, compression wrapping,
exercise therapy, and skin care. This highly successful treatment regimen has become the standard
of care for lymphedema management [ 10 , 14 – 16 ].
Signifi cant improvement and reduction of swelling
is often readily apparent after treatment (Fig. 23.4 ).
Compression wrapping in various forms has
been a long-standing treatment of both venous
and lymphatic edema [ 10 , 17 – 20 ]. Lymphatic
wrapping techniques are complex and utilize lowstretch bandages instead of the more traditional
high-stretch elastic bandages. High-stretch wrapping produces high pressures at rest that decrease
with limb muscle contraction and movement. This
Increasing
compression
Fig. 23.6 Graduated compression stockings. Graduated
compression stockings have the highest pressure at the
ankle level. The pressure decreases up the leg where the
pressure is the lowest at the highest level. The ideal compression for lymphedema treatment is 30–40 mmHg
decreases the ability of the wrap to raise the tissue
pressure during exercise, reducing the hydrostatic
pressure gradient and resulting in a reduction in
stimulation of lymphatic fl ow [ 10 , 17 – 20 ].
In contrast, low-stretch wrapping provides
resistance during muscle pump action that results
in an increase in pressure gradient and stimulates
increased fl uid fl ow [ 10 , 17 – 20 ]. Patients with
signifi cant obesity, pain problems, or advanced
disease may not be able to comply with the complexities of wrapping. For these patients, static
gradient compression devices are available.
The use of elastic compression garments is the
mainstay of the maintenance portion of any
lymphedema management program [ 10 , 17 – 21 ].
Compliance with daily use of compression stockings or sleeves is critical for maintenance of limb
size and volume. Compression garments should
have graduated compression where pressure is
highest distally and decreases proximally where
the pressure is lowest at the highest level
(Fig. 23.6 ). For an upper extremity graduated
compression sleeve, pressure is highest at the
hand/wrist and is lowest at the shoulder. For a
lower extremity graduated compression stocking,
pressure is highest at the ankle and is lowest at the
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Fig. 23.7 The Flexitouch
system pneumatic compression device. This pneumatic
compression device closely
mimics manual lymphatic
drainage with the use of
multiple small compression
chambers. Compression
sleeves for the lower
extremity ( top ) and upper
extremities and trunk
( bottom ) are available
337
knee, thigh, or waist, depending on the length of
the stocking. Recommended graduated compression is 30–40 mmHg for the lower extremity
[ 10 , 18 ]. Upper extremity lymphedema sleeves
are available with a graduated compression of
20–30 mmHg, which is usually adequate [ 10 , 18 ].
In addition to providing graduated compression, compression stockings and sleeves also
assist with venous return, help preserve skin
integrity, and protect the skin from trauma [ 10 ].
Currently, there are many manufacturers who
produce graduated compression stockings and
sleeves with different pressure strengths, different fabrics, and multiple color options. The ability to independently don the compression garment
is critical. Numerous devices are available to
assist with stocking and sleeve donning.
For decades prior to the introduction of CDT,
pneumatic compression pumps were the mainstay of lymphedema therapy. Since the mid1990s, when CDT became more widely available,
the use of pneumatic compression pump therapy
has largely become an adjunct to CDT in both the
reductive and maintenance phases [ 3 , 10 , 14 , 22 ].
The majority of pneumatic compression pumps
perform sequential pumping of the affected
lymphedematous limb from distal to proximal.
These devices augment the benefi cial effects of
the standard modalities of CDT. There is a new
class of sequential pneumatic compression
device, known as the Flexitouch system. This
pneumatic compression device closely mimics
MLD with the use of multiple small compression
chambers (Fig. 23.7 ).
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J. Laredo and B.B. Lee
23.8.3 Prevention of Infection
Prevention of acute episodes of cellulitis or lymphangitis is critical because they cause severe
deterioration in swelling and result in further
injury to the lymphatic system [ 12 , 21 , 22 ]. Care
of the skin, good hygiene, control of skin diseases
such as tinea pedis, and careful antiseptic dressing
application after minor wounds are all important.
Antibiotics must be administered promptly when
an acute infl ammatory episode occurs. There are
no defi nitive studies addressing antibiotic prophylaxis for patients at risk for lymphedema, but
evidence has shown the relationship between
chronic fungal infection and the development of
cellulitis, which is known to increase the potential
for lymphatic failure [ 12 , 22 ].
23.8.4 Pharmacologic Treatment
Diuretics are of little benefi t in patients with
lymphedema because the pharmacologic effects
only limit capillary fi ltration [ 2 , 3 ]. Improvement
in lymphedema patients who are taking diuretics
suggests that the predominant cause of edema is
not lymphatic and is likely due to another undiagnosed etiology. In cases where increased hydrostatic pressure is also elevated, such as the
postphlebitic syndrome with secondary hypertension, low-dose thiazide-induced diuresis may
play a benefi cial complementary role to compression therapy [ 12 ].
Coumarin, a benzopyrone medication, has
been reported to be of benefi t to patients with
lymphedema [ 23 ]. However, the poor study
design of most of the coumarin trials limits interpretability. The therapeutic benefi t, if present, has
been theoretically ascribed to its effects on cutaneous macrophages and, thereby, on local proteolysis. The medication also stimulates other
cellular elements of the immune system and may
promote protein reabsorption. Despite some
encouraging early trials, coumarin must still be
considered experimental [ 23 – 25 ]. In addition, its
associated risk of hepatotoxicity makes this medication an even much less attractive treatment
option [ 3 , 23 ].
23.8.5 Surgical Therapy
In situations where CDT fails to improve the size
and weight of a lymphedematous limb that is so
large, it inhibits its use and interferes with mobility and function, and surgery may be of value.
Surgery is aimed at either removing excessive
tissue (excisional procedures) or bypassing local
lymphatic defects (lymphatic reconstruction procedures) [ 4 , 26 ]. CDT is still required after surgi-
cal excision and reconstruction.
Excisional procedures usually involve staged
removal of the lymphedematous subcutaneous
tissue of the leg [ 26 – 29 ]. The most radical exci-
sional operation, the Charles procedure, involves
total skin and subcutaneous tissue excision of the
lower extremity from the tibial tuberosity to the
malleoli, followed by skin grafting. The main
complications associated with this procedure and
other excisional procedures are infection and
necrosis of the skin graft [ 26 ].
Chronic lymphedematous tissue transforms
with time into adipose tissue, which cannot be
reduced by massage or compression treatment.
Liposuction aimed at removing this adipose tissue has been reported to be benefi cial in treating
lymphedematous limbs [ 28 , 29 ]. This procedure
is not routinely performed for treatment of
lymphedema.
Developments in microvascular techniques
have allowed surgical attempts at direct lymphatic
reconstructions, performance of lymphaticvenous anastomoses, or lymphatic grafting [ 26 ,
30 , 31 ]. These reconstructions are usually indi-
cated in only a small subset of patients who have
proximal obstruction with preserved lymphatic
vessels distally.
The best outcomes are seen in patients with
secondary lymphedema, with well-defi ned
trauma to the lymphatics, seen on lymphatic
imaging, who underwent lymphatic to venous
anastomoses [ 30 , 31 ].
Lymphatic bypass procedures are only performed in a few selected cases and in only a few
specialized medical centers. This is refl ected in
the literature by small patient numbers in most
series reported [ 26 ]. Results are variable, and
lymphatic bypass procedures are generally not
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339
routinely performed except at these few specialized medical centers.
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3. Rockson SG. Diagnosis and management of lymphatic vascular disease. J Am Coll Cardiol. 2008;
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4. Tiwari A, Cheng KS, Button M, Myint F, Hamilton G.
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5. Ely JW, Osheroff JA, Chambliss ML, Ebell MH.
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Board Fam Med. 2006;19(2):148–60.
6. Alitalo K, Tammela T, Petrova TV. Lymphangiogenesis
in development and human disease. Nature. 2005;
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7. Rooke TW, Felty C. Lymphedema: pathophysiology,
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Hodder Arnold; 2009. p. 629–34.
8. Kerchner K, Fleischer A, Yosipovitch G. Lower
extremity lymphedema update: pathophysiology,
diagnosis, and treatment guidelines. J Am Acad
Dermatol. 2008;59(2):324–31.
9. International Society of Lymphology. The diagnosis
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Lymphology. Lymphology. 2009;42(2):51–60.
10. Gamble GL, Cheville A, Strick D. Lymphedema:
medical and physical therapy. In: Gloviczki P, editor.
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Hodder Arnold; 2009. p. 649–57.
11. Lee B, Andrade M, Bergan J, Boccardo F, Campisi
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Angiol. 2010;29(5):454–70.
12. Mortimer PS. ABC of arterial and venous disease
swollen lower limb – 2: Lymphoedema. BMJ. 2000;
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Taylor ME, Thiadens SR. Lymphedema management.
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15. Mayrovitz HN. The standard of care for lymphedema:
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Venous Leg Ulcers
https://t.me/med1917
Robert B. McLafferty
2 4
Contents
24.1 Introduction ................................................ 341
24.2 Basic Principles .......................................... 342
24.2.1 History and Physical Examination ............... 342
24.2.2 Laboratory Assessment ................................ 343
24.2.3 Microbial Culture Evaluation ...................... 343
24.2.4 Skin/Ulcer Biopsy ........................................ 344
24.2.5 Wound Assessment ...................................... 344
24.2.6 Noninvasive Vascular Testing ...................... 344
24.2.7 X-Ray Evaluation......................................... 344
24.3 Venous Ulcers ............................................. 345
24.3.1 Epidemiology ............................................... 345
24.3.2 Pathophysiology ........................................... 345
24.3.3 History and Physical Examination ............... 345
24.3.4 Management................................................. 346
24.4 Leg Ulcer Differential Diagnosis............... 349
24.4.1 Arterial Ulcers .............................................. 349
24.4.2 Diabetic Ulcers ............................................ 349
24.4.3 Pressure Ulcers ............................................ 350
24.4.4 Infectious Ulcers .......................................... 350
24.4.5 Vasculitic Ulcers .......................................... 351
24.4.6 Pyoderma Gangrenosum .............................. 351
24.5 Summary..................................................... 351
References ................................................................. 352
Abstract
Venous leg ulcers are the most common form
of leg ulcer. While there are many rare causes
of ulcerations that can occur from knee to the
toes, the overview provided herein gives the
practitioner guidance on how to evaluate a
patient presenting with a leg ulcer and care
for and heal the venous ulcer and information about other more common types of
ulcers that are in the differential diagnosis.
Fortunately, history and physical examination can help determine, with some confi rmatory tests, the type of ulcer. Nevertheless,
the essentials of wound healing remain the
same for the large majority of ulcers on the
lower extremities. Healing will hasten if
treatment of all leg ulcers includes assuring
adequate perfusion; removing nonviable tissue; reducing infl ammation and eliminating
infection, relieving edema; optimizing tissue
growth; off-loading or providing pressure
relief; controlling pain; and treating host systemic disease or conditions such as diabetes
and nutrition.
R. B. McLafferty , MD, FACS, RVT
Division of Vascular Surgery, Department of Surgery ,
Southern Illinois University, School of Medicine ,
Springfi eld , IL , USA
e-mail: robert.mclafferty@va.gov
E. Mowatt-Larssen et al. (eds.), Phlebology, Vein Surgery and Ultrasonography,
DOI 10.1007/978-3-319-01812-6_24, © Springer International Publishing Switzerland 2014
24.1 Introduction
Chronic ulceration of the lower leg and foot continues to be one of the more formidable clinical
problems in medicine. Conditions leading to
ulceration of this susceptible region of the body
frequently cause pain, disability, social stigma,
and considerable costs. Burden on family
341
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R.B. McLafferty
members, caretakers, and medical facilities as
well as the economic strain from inability to
work can be high, further complicating the pathway to healing. A staggering 1 % of the population will suffer from chronic ulceration of the leg
during some time over a lifetime [ 1 , 2 ]. The
prevalence of leg ulcerations increases with age
and ranges from 3 to 5 % in the adult population
over the age of 65 years [ 1 – 4 ]. In one study from
the UK, the prevalence of venous ulcers alone in
individuals over the age of 65 was estimated to
be 1–2 % [ 5 ].
Although there are varying defi nitions of the
term ulcer, the two prerequisites include full
thickness obliteration of the epidermis and dermis with no sources of epithelialization in the
center of the ulcer combined with the tendency of
slow healing. Generally, as compared to an acute
wound, a slow-healing ulcer is defi ned as being
present for more than 4 weeks. Reasons for
chronic ulcers are not necessarily related to depth
and size but often associated with an underlying
disease manifestation (systemic, local, or both)
that requires specialized treatment in order to
induce healing.
Dividing the causes of ulcers into common
and rare etiologies helps in the construction of
an accurate differential diagnosis. The most
common causes of leg ulcers are chronic venous
disease (45–90 %), diabetes mellitus (15–25 %),
arterial ischemia (10–20 %), or a combination
of two or more of these etiologies (10–15 %)
[ 6 – 9 ]. Less common causes of ulcers, but not
necessarily rare, include infections, decubitus
(pressure), and vasculitis. This chapter will primarily focus on the diagnosis and care for
venous leg ulcers and also briefl y outline evaluation and treatment options of other causes of
leg ulcers in the differential diagnosis. The
importance of correct diagnosis cannot be over
emphasized as diagnostic tests and treatments
can vary dramatically. Alternatively stated,
incorrect diagnosis can lead to incorrect treatment and hence result in further harm to the
patient with a leg ulcer.
24.2 Basic Principles
24.2.1 History and Physical
Examination
When performing a fi rst-time evaluation on a
new patient with a chronic leg ulcer, several basic
principles should be followed in addition to a
complete history and physical examination. The
patient’s story of how the ulceration began is
important and may give rise to clues as to the
type of ulcer. Did the ulcer occur spontaneously
from seemingly normal-appearing skin or were
there preceding symptoms or signs such as pain,
tenderness, itching, swelling, skin discoloration,
infl ammatory changes, or blisters? Other important aspects of the ulcer include location, size,
duration, and symptoms. Do the symptoms vary
with time of day or position?
Further clues in the history regarding the
patient’s overall medical condition include
whether or not the patient has had deep venous
thrombosis or pulmonary embolism; whether the
patient has diabetes mellitus; and whether the
patient has risk factors for atherosclerotic disease
such as smoking, hypertension, hyperlipidemia,
or chronic renal insuffi ciency. Past history of
other events related to atherosclerosis such as
stroke, coronary artery disease, or claudication
should be elicited. Infl ammatory conditions such
as rheumatoid arthritis, lupus erythematosus, or
infl ammatory bowel disease are also important.
Other pertinent information include whether the
patient has had fever or rigors, recent trauma or
surgery, a change in types of shoes being worn, or
a history of whether there are any sensory defi cits, particularly in the forefoot.
The physical exam from below the knees to
the toes requires close methodical inspection and
palpation. Vitally important areas to be assessed
include the skin on the posterior heel and ankle
as well as the web spaces between the toes. Nails
deserve close scrutiny and should be described
in detail. Bony deformities such as partial foot
amputation, bunion, hammertoes, metatarsal head
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